Program examines IT solutions to monitor older patients’ care

WORCESTER, Mass. —Nearly 60 percent of older adults in the United States use five or more different medications per week, and nearly 1-in-5 uses 10 different medications. Hospital and emergency room visits may further complicate the tracking of medications between patient, primary care physicians and hospital doctors.

In response, researchers at the Meyers Primary Care Institute, a collaboration of the University of Massachusetts Medical School, the Fallon Clinic and Fallon Community Health Plan, are starting a project to test health-information technology tools as solutions to the dangers of handoffs from hospitals to primary care providers when it comes to prescribing and monitoring medications in people over 65 years old.

Institute executive director Dr. Jerry Gurwitz will lead the study, funded by a three-year, $1.2 million grant from the federal Agency for Healthcare Research and Quality. The goal is to see if systems based on patients’ electronic health records prevent adverse drug events, emergency room visits and repeat hospitalizations. AHRQ is making similar grants across the country focusing on transitions in medical care.

For years researchers focused their attention on identifying particular drugs that posed hazards for older people, advising doctors to avoid prescribing them. But the problem isn’t so simple, Gurwitz said, citing a study published a few months ago in the Journal of the American Medical Association. Researchers from the Centers for Disease Control and Prevention discovered that those few drugs accounted for only about 3 percent of problems related to older people who arrived at emergency rooms with adverse drug events, from allergic reactions to overdoses to falls.

“We’ve come to the conclusion that it’s really all the drugs that doctors and other healthcare providers prescribe,” Gurwitz said. “It’s not just a certain finite list of medications that lead to problems. Mainly it’s how drugs are used, how drugs are prescribed, how drugs are monitored and how patients take them that can lead to problems.”

A lot of hope is being placed in health information technology to solve these problems, he said, but until electronic interventions are tested, the jury is still out.

That’s where the conversion to electronic health records, completed last year at Fallon Clinic, comes in. The Meyers study will test what is known as a medication-reconciliation system on the nearly 30,000 members of insurer Fallon Community Health Plan’s senior plan who get their medical care from Fallon Clinic. When members of the plan go to hospital emergency rooms or become hospitalized, their primary care physicians, in some cases, will receive e-mail alerts about changes in their medications and be notified when high-risk medications require additional monitoring.

People who schedule appointments also will receive alerts, and additional messages will be sent if the appointments or lab tests don’t happen.

“Right now, a piece of paper is faxed to primary care physicians, but we’re going to use technology to highlight the changes to make sure it’s very clear what’s happened to the medications, what’s been stopped, what’s been started and what kind of monitoring needs to take place,” said Dr. Lawrence Garber, an internal medicine doctor and architect of Fallon Clinic’s transition from paper to electronic medical records. Garber, Dr. Jennifer Tjia and Dr. Terry Field are co-investigators on the Meyers project.

“The ultimate goal is to keep the primary care physician fully in the loop, as the patient transitions from hospital to home,” Gurwitz said. Researchers will assess the impact of this new system on preventable adverse drug events, emergency room visits and repeat hospitalizations.

The Meyers project concentrates on that vulnerable period after hospital discharge. It seems like a no-brainer that alerts and prompts doctors visits will help, Gurwitz said, but then there’s also the danger of “alert fatigue,” when so many things are flagged that an overloaded clinician no longer pays attention.

“There are people who believe in this with almost religious fervor, but there’s always the risk of unintended things happening,” Gurwitz said. “We have to figure out what works and what doesn’t.”

Garber thinks the timing is right for such a trial.

“With the advent of electronic health records, we have the tools to allow us to do the interventions so that we can eliminate preventable adverse events,” he said. “We now have the toolbox that allows us to make any fix we need to do. We just need to know which fixes.”